Whitney Child Centre Enrolment/Emergency FormStudent Surname Student Name Date of Admission Day Month Year Male Female (Please circle) Date of Birth Day Month Year Home Address Postal Code Home Phone Email Address Parent 1 InformationHome address as above or: Parent/Guardian Name Home Address, as above or: Postal Code Home Phone Cell Phone Business Phone Email Address Parent 2 InformationHome address as above or:Parent/Guardian Name Home Address Postal Code Home Phone Cell Phone Business Phone Email Address Business Address for one parent Postal Code Parent 3 InformationHome address as above or: Parent/Guardian Name Home Address, as above or Home Phone Cell Phone Business Phone Email Address Parent 4 InformationHome address as above or: Home Address, as above or Home Phone Cell Phone Untitled Business Phone Email Address Business AddressPlease indicate which parent (1,2,3,4) Business Address Postal Code Phone Child's Name Emergency Contact 1Other than parent/guardianName Relationship Address including Postal Code Home Phone Bus/Cell Phone Emergency Contact 2Other than parent/guardianName Relationship Address including Postal Code Home Phone Bus/Cell Phone Doctor InformationName of Doctor Doctor's Address Postal Code Phone Date of last tetanus shot (DPTP) Day Month Year Drug AllergiesFood/Other AllergiesDoes your child have anaphylactic symptoms? What symptoms do you see if your child is exposed to allergen?Dietary RestrictionsAny medical conditionsOther than parents, people authorized to pick up your childName Relationship Phone Name Relationship Phone Name Relationship Phone Name Relationship Phone Parent SignatureName Date Day Month Year
